FINANCIAL POLICY & AGREEMENT
|
|
|
- Tamsin Blair
- 5 years ago
- Views:
Transcription
1 BACK TO HEALTH CHIROPRACTIC WELLNESS CENTER, P.C Chicago Drive Zeeland, MI (616) FINANCIAL POLICY & AGREEMENT SOURCE OF PAYMENT The Financial Policy of Back to Health Chiropractic Wellness Center, P.C. (the "Company") requires payment in full for all services rendered at the time of your visit, unless other arrangements have been made. The Company generally accepts payment from the sources identified below. If you have any questions related to your available sources of payment, please ask any staff member of the Company. PRIVATE PAY (NO INSURANCE) If you do not have insurance or another party who may be responsible for paying for your health expenses, you are responsible for payment and must bring your account current at each visit. As a service to you, the Company offers no-interest and low-interest financing through CareCredit Patient Payment Plans. Please ask a staff member of the Company for more information related to payment plans, if you are interested. PERSONAL INJURY or AUTOMOBILE ACCIDENTS Injuries sustained as a result of an auto- related incident will be submitted under a personal injury claim. Please provide your automobile insurance information, claim number, insurance adjuster's contact information and health insurance information so that the Company can promptly process your claims. If an attorney is handling your case, please notify the Company as soon as possible. Although you are ultimately responsible for payment, the Company will wait for payment until your claim is settled, so long as you are an active patient. If you suspend or terminate care, any fees for services are due immediately. ON THE JOB INJURY (Workers' Compensation) If you are injured on the job, your care may be paid for under your employer s Workers Compensation insurance policy. You will need to inform your employer of the accident. Please provide the contact information for your employer's Workers' Compensation insurance carrier, your claim number, and your health insurance information so that the Company can promptly process your claims. If an attorney is handling your case, please notify the Company as soon as possible. Although you are ultimately responsible for payment, the Company will wait for payment until your claim is settled, so long as you are an active patient. If you suspend or terminate care, any fees for services are due immediately. MANAGED CARE PLANS The Company are preferred providers for the following HMO s and PPO s: Aetna, ASR Health (Physician s Care), Assurant Health, Blue Care Network, Blue Cross Blue Shield, Cigna, Cofinity, Humana, Medicare, Meridian, Meritain, Priority Health, United Health Care. Please note your insurance may be a subsidiary of the previously listed insurance companies. Please contact your HMO or PPO directly to discuss the benefits available to you, your responsibility for paying cost-sharing amounts, and any referral requirements. FLEX PLANS/MEDICAL SAVINGS ACCOUNT PLANS Upon request, the Company will provide you with a statement of your charges for your use in seeking reimbursement under a Flex Plan or Medical Savings Account Plan. MEDICARE The Company accepts Medicare reimbursement for services rendered to you. However, Medicare covers only medically necessary manipulation of the spine and will only pay for 80% of the allowable fee once the deductible has been met. You will remain responsible for the remaining portion of the allowable fee, any deductible, and all other services or tests (including X-rays and examinations). The Company will make every reasonable attempt to secure payment for your services from Medicare. INSURANCE The Company accepts assignment of insurance benefits in lieu of cash payments for certain services rendered to you. The Company is willing to investigate the availability of insurance benefits, upon request. If so requested, you must provide accurate and up-to-date insurance information. Please be prepared to present your insurance identification card at each visit. The Company's communication with your insurance company is not a guarantee of payment. The Company encourages you to contact your insurance company directly for detailed coverage information. The Company will also assist you if you need help in filing claims with secondary insurance providers. The Company attempts to keep track of individual insurance plans and the amounts that they typically pay for procedures. However, plans routinely change, thus the estimated insurance payment may vary from your insurance company s actual payment. When your insurance payment is received, any necessary adjustments (credits or debits) will be made to your account.
2 It is important to remember that your insurance coverage is a contract between you, your employer (if applicable), and your insurance company. While the Company will seek payment from your insurance provider before looking to you for payment, you are responsible for certain upfront fees. These may include, among other fees, co-payments, deductibles and co-insurance amounts, as applicable. You will also be responsible for any amount that is not covered by insurance. PAYMENT POLICY 1. Payment is due at the time of service, unless other arrangements have been made. 2. For your convenience, the Company accepts cash, checks, CareCredit (payment plan), Visa, MasterCard and Discover. 3. An insurance contract is between you, your employer, and your insurance company; therefore, it is your responsibility to keep the account current. 4. You will be notified when your insurance reimbursement goes beyond 45 days without payment. At that time, you should contact your insurance company to request payment. After 90 days, you will be billed and expected to make payment in full. 5. Patients involved in litigation (law suits) are responsible for payment of their services, as outlined above. In its discretion, the Company may agree to wait for payment until the final disposition of your claims is reached, so long as you are an active patient. 6. Any fees for services rendered will be immediately due and payable if you suspend or terminate care. 7. Any amount paid to the Company relates to services only; x-rays, medical records, and other physical property will remain the permanent property of the Company hours' notice is required when cancelling or rescheduling appointments. The Company reserves the right to charge up to the full amount owed for scheduled services in the event you do not cancel with a 24-hours' notice (including no-show appointments). Cancellation fees are your responsibility, will not be charged or submitted to insurance, and must be paid in full before your next visit. 9. In the event that your check is returned due to insufficient funds, you will be assessed a $25 fee. ASSIGNMENT AND AUTHORIZATION I hereby assign to the Company all medical and other benefits, including major medical benefits, related to the services provided to me by the Company. I further authorize and direct my insurance carriers (including Medicare, private insurance and any other health or medical plan) to issue payment directly to the Company for services rendered to me and/or my dependents. I understand that I am responsible for any amount not covered by insurance. I also agree to pay the Company any money that I receive from my insurance carrier for services provided to me for which I have not paid the Company. I hereby authorize the Company to release all information necessary to secure the payment of benefits. I authorize the use of my signature on all my insurance submissions whether manual or electronic. Furthermore, I authorize the release of my medical records, including protected health information, to secure payment and/or to receive medical information pertaining to my case in the Company s clinic. If my account is delinquent, I agree to pay all expenses incurred by this office to collect the account. This includes, but is not limited to, items such as collection agency fees, court costs, and attorney fees. My signature indicates my understanding and agreement to the policies stated above. x Signature of Patient or Parent/Guardian Printed Name of Patient Parent or Guardian Name (if minor patient)
3 Patient Acknowledgement and Receipt of Notice of Privacy Practices Pursuant to HIPAA and Consent for Use of Health Information Name Print Patient s Name The undersigned does hereby acknowledge that he or she has received a copy of this office s Notice of Privacy Practices Pursuant To HIPAA and has been advised that a full copy of this office s HIPAA Compliance Manual is available upon request. The undersign does hereby consent to the use of his or her health information in a manner consistent with the Notice of Privacy Practices Pursuant to HIPAA, the HIPAA Compliance Manual, State law and Federal Law. d this day of, 20 By Patient s Signature If patient is a minor or under a guardianship order as defined by State law: By Signature of Parent/Guardian (circle one)
4 BACK TO HEALTH CHIROPRACTIC WELLNESS CENTER, P.C Chicago Drive Zeeland, MI (616) COMMUNICATION STATEMENT As a convenience to our patients, Back To Health offers three options for appointment reminders. Please choose one option. (All options are a 24 hour notice unless you request otherwise). OR Phone Call: Please leave a phone message at OR Text Message: A text message at Circle your phone provider: (Notice your phone company may charge you extra if you do not have a texting plan) AT&T/Cingular Verizon Sprint Metro PCS Nextel T Mobile Cricket Virgin Mobile Other: In addition, we will mail our written communications to the address you specified on your patient intake form unless you request otherwise. This includes communications with a birthday gift for active patients, occasional news, specials and events. (HIPPA laws do not allow us to give your or address to third parties). If you wish not to receive our s, there will be a removal button at the bottom of every , which will immediately remove you from future mailings. (Sorry, our birthday gift is only available to those patients that are on our list). Patient/ Representative Signature
5 BACK TO HEALTH CHIROPRACTIC WELLNESS CENTER, P.C Chicago Drive Zeeland, MI (616) CHIROPRACTIC INFORMED CONSENT SCOPE OF TREATMENT Your treatment will primarily involve chiropractic procedures performed by the Doctor of Chiropractic who is named below, or another licensed Doctor or support staff member of Back to Health Chiropractic Wellness Center, P.C. Such chiropractic procedures may involve the manual or mechanical manipulation of your joints and body. The movement may cause an audible "popping" or "clicking" noise, similar to the sound made when you crack your knuckles. As part of your treatment, the Doctor or staff member may also conduct spinal manipulative therapy, adjustments, range of motion testing, muscle strength testing, massage therapy, postural analysis, ultrasounds and x-rays. You must inform the Doctor prior to treatment if you are pregnant, as x-rays may be hazardous to an unborn child. There are other treatment options available that may be available for your condition that do not involve chiropractic procedures. They include surgery, hospitalization, bracing, physical therapy, steroid injections, prescription drugs, muscle relaxers and over-the-counter painkillers, among others. Please note that these other treatment options also involve their own risks. RISKS Chiropractic treatment does not guarantee certain results or promise to cure any ailments. Additionally, as with any health care treatment, chiropractic treatment involves certain complications or risks. These may include, but are not limited to, the following: stiffness or soreness; muscle strain or spasms; aggravation or an increase of symptoms; disc injuries; dislocations; fractures; and stroke. Please also note that remaining untreated may also involve certain risks and may hinder the success of any future treatment. It is very common for patients to experience slight stiffness after treatment. More serious complications, such as fractures, are rare and generally result from an underlying bone weakness. The incidences of stroke are also exceedingly rare, and have been estimated to occur between one in one million and one in five million cervical adjustments. Your Doctor will make every reasonable effort to lessen any risks of treatment, but he or she may not be able to anticipate all complications. You are responsible for informing the Doctor if you have a condition or experience any symptoms that may not otherwise come to the Doctor's attention. CONSENT I have read, or have had read to me, this Informed Consent. I have discussed it with the Doctor who is named below and have had the opportunity to ask questions about it. By signing below, I acknowledge that I agree to receive treatment, understand the risks involved and consent to that treatment. I intend for this Informed Consent to cover the entire course of my treatment with Back to Health Chiropractic Wellness Center, P.C., including any future conditions for which I may seek treatment. I wish to rely on the Doctor to exercise his or her best judgment during the course of my treatment to accomplish what he or she feels to be in my best interests. DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE INFORMED CONSENT. x Signature of Patient or Parent/Guardian Printed Name of Patient Parent or Guardian Name (if minor patient) x Signature of Doctor of Chiropractic Printed Name of Doctor of Chiropractic Reaffirmed Consent: Initial
6 Electronic Health Records Intake Form In compliance with requirements for the government EHR incentive program First Name: Last Name: address: DOB: / / Gender (Circle one): Male / Female Preferred Language: Smoking Status (Circle one): Every Day / Occasional / Former / Never Smoking Start (Optional): CMS requires providers to report both race and ethnicity Race (Circle one): American Indian or Alaska Native / Asian / Black or African American / White (Caucasian) / Native Hawaiian or Pacific Islander / I Decline to Answer Ethnicity (Circle one): Hispanic or Latino / Not Hispanic or Latino / I Decline to Answer Are you currently taking any medications? (Please include regularly used over the counter medications) Medication Name Dosage and Frequency (i.e. 5mg once a day, etc.) Do you have any medication allergies? Medication Name Reaction Onset Additional Comments Patient Signature: (Parent/ legal guardian signature if patient is under 18 years old) : For office use only Height: Weight: Blood Pressure: / Pulse: Back To Health Chiropractic Chicago Drive Zeeland, MI P (616) F (616)
ACKNOWLEDGMENT OF RECEIPT OF HIPAA PRIVACY NOTICE
WELCOME to our office! Please allow our staff to make a photocopy of your insurance card(s) (if applicable). Please Print Clearly PERSONAL INFORMATION: Patient Name: Preferred Name: Address: City/State/Zip:
Welcome to Phillips Family Chiropractic
Welcome to Phillips Family Chiropractic Name: Age: DOB: / / SS# / / Address: City: State: Zip Code: Phone: ( ) - Employer: Occupation: Circle One: Single / Married Number of Children: Email: Spouse: Employer:
Welcome to MARTIN CHIROPRACTIC
Welcome to MARTIN CHIROPRACTIC 225 E. Buena Vista Street, Barstow, CA 92311 (760)-256-2171 www.drscottmartin.com Name: Date of Birth Age Last First Middle Initial Address: Social Security # City State
List the names of any relatives that have or have had a similar problem. CMS requires providers to report both race and ethnicity
APPLICATION FOR TREATMENT Date Name: Age: Date of Birth: Address: City State ZIP Phone: Home Work Cell Email: Preferred method for appointment reminders: [] Email []Phone [] Mail Marital Status: [] Married
HAMILTON FOOT AND ANKLE CARE, LLC 9865 E. 116 th St. #300 Fishers, IN (317)
HAMILTON FOOT AND ANKLE CARE, LLC 9865 E. 116 th St. #300 Fishers, IN 46037 (317)-284-8888 Patient Name: Date of Birth: / / First MI Last SS#: Address: City: State: Zip Code: Cell Phone: ( ) - Home Phone:
PATIENT APPLICATION FORM
PATIENT APPLICATION FORM WELCOME TO OUR CLINIC! We specialize in assisting our patients to achieve their highest level of health through our spinal and postural corrective programs. Our approach is very
Are you currently pregnant? ( ) Yes, due date: ( ) No ( ) Unsure
Patient s Full Name: of Birth: Age: Address: City: State: Zip: Patient Social Security #: Gender: Height: Weight: Cell Phone: Other Phone: E-Mail: Preferred appointment reminder: ( )Text: Cell Phone Provider:
IF THE INSURANCE INFORMATION IS NOT IN YOUR NAME WE MUST HAVE THE FOLLOWING.
A FAMILY TRADITION ROBERTS CHIROPRACTIC CENTER, PA Date of appointment: Name: Last First Middle Name No nicknames please Birth date Address: Please no P. O. Boxes Age: Sex: F M City State Zip Are you Hispanic?
GRAHAM CHIROPRACTIC CENTER, INC. BRYAN GRAHAM, DC, CCSP
GRAHAM CHIROPRACTIC CENTER, INC. BRYAN GRAHAM, DC, CCSP 34 Long Pond Road Plymouth, MA 02360 (508) 747-1434 New Patient Intake Form Patient Information Thank you for choosing our practice for your chiropractic
WELCOME TO FETZER FAMILY CHIROPRACTIC
WELCOME TO FETZER FAMILY CHIROPRACTIC Patient Information Thank you for choosing Fetzer Family Chiropractic for your health care needs. Please complete this form in ink. If you have any questions or concerns,
Austin Kinesiology And Chiropractic
PATIENT INFORMATION Patient Name: Date of Birth: Sex: M F Age: Soc. Sec. #: - - Photo ID #: State: Address: City, State, Zip: Mobile Phone: Home Phone: Work Phone: Email address: We will not share your
PATIENT INFORMATION Patient First Name Middle Name Last Name Age Birth Date. Mailing Address City State Zip. Street Address City State Zip
PATIENT INFORMATION Patient First Name Middle Name Last Name Age Birth Date Mailing Address City State Zip Street Address City State Zip Home Phone Cell Phone Employer Name (for work comp only) Employer
(Please Print using Black or Blue Ink) SEX: GENDER IDENTITY: MARITAL STATUS: SINGLE MARRIED OTHER
PATIENT INFORMATION (Please Print using Black or Blue Ink) LAST NAME: FIRST NAME: MIDDLE INITIAL: ADDRESS: CITY: STATE: ZIP: SEX: GENDER IDENTITY: MARITAL STATUS: SINGLE MARRIED OTHER RACE (OPTIONAL):
C.A.I. A Cardiovascular & Arrhythmia Institute
Acknowledgement of Receipt of Notice of Privacy Practices By signing below I acknowledge that I have received the Notice of Privacy Practices of Cardiac Arrhythmia Institute, LLC, which explains its legal
Practice Member Health Questionnaire
89 Route 101A Amherst, NH 03031 Practice Member Health Questionnaire Name What do you prefer to be called? Home Phone Cell Phone Work Phone Address City, State, Zip of Birth Would you like text message
Patient Registration & Health History
Patient Registration & Health History Today s Date: / / How did you hear about us? Legal Name: How do you prefer to be addressed? Address: City: State: Zip: Date of Birth / / Age: Gender: M / F Marital
PATIENT MEDICAL RECORD # DATE OF BIRTH / / Male: Female: PATIENT NAME LAST FIRST MI FORMER LAST NAME MAILING ADDRESS CITY STATE ZIP
PATIENT INFORMATION PATIENT MEDICAL RECORD # DATE OF BIRTH / / Male: Female: PATIENT NAME LAST FIRST MI FORMER LAST NAME MAILING ADDRESS CITY STATE ZIP HOME PHONE ( ) WORK PHONE ( ) CELL PHONE ( ) E-MAIL
PATIENT REGISTRATION
PATIENT REGISTRATION Today s Date Last Name First Name Address City, State, Zip Email Address Home Phone Work Phone Cell Phone SS# Date of Birth Age Sex ( ) Male ( ) Female Marital Status (check one):
Patient Intake Form Patient Information
Patient Intake Form Patient Information Full Name: First MI Last Date: Address: City: State: Zip: Age: Birth Date: Female: Male: Email Address: Home Phone: Work Phone: Cell/Other: I prefer to receive calls
Other, please explain
: General Information First name: Middle initial: Last name: of Birth: Street address: City State Zip Marital Status: Single Married Other Email Address: Cell Phone: Cell phone provider: Home Phone: Center
Marital Status Patient s Last Name First Initial Date of Birth S M D W. Home Phone Work Phone Mobile Phone . Address City State Zip
PATIENT INFORMATION Marital Status Patient s Last Name First Initial Date of Birth S M D W Home Phone Work Phone Mobile Phone E-Mail Address City State Zip Occupation Employer Employer Phone Employer Address
Patient Case History
Patient Case History Name: Address: City: State: Zip: Home Phone: - - Work Phone: - - Cell Phone: - - Email Address: Preferred Contact: Home Phone Cell Work E-mail Employer & Occupation: Date of Birth:
WELCOME Thank you for selecting our healthcare team! To help us meet your healthcare needs, please fill out this form completely.
Page 1 of 4 WELCOME Thank you for selecting our healthcare team! To help us meet your healthcare needs, please fill out this form completely. Date: Dr: Chart #: Patient s Name: First MI Last Patient s
BACK-HEALTH CHIROPRACTIC INITIAL PATIENT REGISTRATION (2016) Dr. Goudarz Vassigh, DC THIS SECTION REFERS TO PATIENT ONLY
INITIAL PATIENT REGISTRATION (2016) Dr. Goudarz Vassigh, DC PATIENT THIS SECTION REFERS TO PATIENT ONLY Patient: LAST FIRST MIDDLE Address: City, State, Zip: Cell Phone ( ) of birth Male Female Social
WELCOME TO FETZER FAMILY CHIROPRACTIC
WELCOME TO FETZER FAMILY CHIROPRACTIC Patient Information Thank you for choosing Fetzer Family Chiropractic for your health care needs. Please complete this form in ink. If you have any questions or concerns,
Family Foot and Ankle Centers Patient Registration Form (Please present your insurance cards to the receptionist upon arrival)
Family Foot and Ankle Centers Patient Registration Form (Please present your insurance cards to the receptionist upon arrival) Patient s Name First Last M.I. Nickname Address # City State Zip code Phone:
1. PATIENT INFORMATION
Runnels Chiropractic 32 South 9 th Street - Richmond, IN 47374 (765) 96 CHIRO (24476) www.runnelschiro.com 1. PATIENT INFORMATION Today s _ Full Name SSN Age DOB Address City State Zip Height Weight Race
RELEASE OF MEDICAL INFORMATION
Lawrence M. Levine, M.D. P. Vernon Jones, M.D. David W. Hayes, D.O. David A. Green, O.D. Melanie C. Javier, O.D. RELEASE OF MEDICAL INFORMATION I hereby authorize the release of any and all medical records
Have you had Chiropractic Care Before? When? Where? What is your current complaint (be specific)?
Welcome to Rizzo Chiropractic Holistic Health and Wellness Center Check the following services you are interested in: Chiropractic Physical Rehabilitation Nutritional Analysis (Hair, Blood & Urine) Detox
HOME ADDRESS APT. NO CITY STATE ZIP CODE S M D W PRIMARY INSURANCE INFORMATION SUBCRIBER S FIRST NAME LAST NAME RELATIONSHIP TO PATIENT DATE OF BIRTH
PATIENT REGISTRATION FORM PATIENT NAME LAST FIRST MIDDLE INITIAL PATIENT DATE OF BIRTH HOME ADDRESS APT. NO CITY STATE ZIP CODE OCCUPATION EMPLOYED RETIRED STUDENT SOCIAL SECURITY # MARITAL STATUS S M
Personal and Family Health History
Personal and Family Health History Name Date of Service Address Phone: (H) City State Zip (W) E-mail Marital Status S M D W Date of Birth (Age ) Occupation Employer Spouse s Name Spouse s Occupation In
WELCOME TO OUR OFFICE PLEASE PRINT THE FOLLOWING INFORMATION THANK YOU
DATE: / / WELCOME TO OUR OFFICE PLEASE PRINT THE FOLLOWING INFORMATION THANK YOU Richard L. Corbin, DPM, FACFAS PATIENT NAME: LAST FIRST MIDDLE SOCIAL SECURITY NUMBER: / / D.O.B: / / STREET ADDRESS: CITY:
To all of our new patients
ATLAS FAMILY Thank you for choosing Atlas Family Chiropractic. We are committed to providing you with the best possible care and we are pleased to discuss our professional fees with you at any time. Your
Sabates Eye Centers P.O. Box Kansas City, MO (913)
Sabates Eye Centers P.O. Box 26425 Kansas City, MO 64196-6425 (913) 261-2020 Type of Visit: u Routine u Medical Contact Lens Wearer? u Yes u No PATIENT INFORMATION Name (Last, First, Middle Initial) Date
PATIENT INFORMATION. Name Soc. Sec. # - - Last Name First Name Initial Address. City State Zip code. E mail address Sex M F Age Birth date
PATIENT INFORMATION Name Soc. Sec. # - - Last Name First Name Initial Address City State Zip code E mail address Sex M F Age Birth date Home phone Mobile phone Work phone In case of emergency who should
ADULT PATIENT REGISTRATION
PATIENT NAME: (LAST) (FIRST) (M) CELL: ( ) HOME: ( ) PERSONAL E-MAIL: (FOR PATIENT PORTAL) DATE OF BIRTH: / / AGE: GENDER: MALE FEMALE SOCIAL SECURITY: - - MARITIAL STATUS: SINGLE MARRIED WIDOW(ER) OTHER
Patient Name: DOB: Sex: Male/Female. Primary Address: Home Phone: Mobile Phone: Address: Emergency Contact Name and Phone Number:
Patient Registration Patient Name: DOB: Sex: Male/Female Primary Address: Home Phone: Mobile Phone: Email Address: Emergency Contact Name and Phone Number: Primary Language: Race(s): (Circle all that applies)
Welcome to our office!
2007 Rainbow Drive Gadsden, AL 35901 Ph: 256-543-0009 Fax: 256-549-1221 Patient Information Page 1of 2 Welcome to our office! Dr. Shan Tian, D. C. Patient Information Please complete all questions. Today
SUBURBAN GASTROENTEROLOGY
SUBURBAN GASTROENTEROLOGY DARREN KASTIN, MD 1243 Rickert Dr. Telephone 630-527-6450 Naperville, IL 60540 Fax 630-527-6456 Suburban Gastroenterology, Ltd. would like to welcome you and confirm your appointment.
Olde Naples Chiropractic Health Center
Patient Full Name: E-Mail Address: Mailing Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Emergency Contact Name/number: Occupation: Status: Employed Full Time Student Part Time Student
Please print and complete all the enclosed forms and bring them to your first appointment.
Dear Valued Patient, Thank you for requesting an appointment in our office. Please print and complete all the enclosed forms and bring them to your first appointment. When you arrive at our office for
SHEDDON PHYSIOTHERAPY AND SPORTS CLINIC
INTAKE FORM Patient First Name Patient Last Name Date of Birth: / / DD month YYYY Address: City: Prov: Postal Code: Mobile Tel: Home Tel: Accepts to receive SMS Text message appointment reminders *E-mail:
Ravi Yalamanchili M.D, P.A. Patient Registration / Information Sheet Last Name: M.I. Sex: Female Male First Name: Marital Status:
We do not Accept Checks Ravi Yalamanchili M.D, P.A. 141 Thomas Johnson Drive, Suite 200 Frederick, MD 21702 Phone 301-846-0100 Fax 301-846-0244 Please Print Patient Registration / Information Sheet Last
PATIENT REGISTRATION FORM
Today s PATIENT REGISTRATION FORM PATIENT INFORMATION Last Name: First: Mi. Init: DOB: Age: SSN: Gen: M F Marital Status: S M D W Race: African American American Indian Asian Caucasian Hispanic Pacific
PHARMACY INFORMATION
NAAMAN CLINIC TODAY S DATE: Prefix Mr. Mrs. Miss Ms. Dr. Preferred Name: Patient s Name Address: First Middle Last Street & Apt # City State Zip SS# Birthdate Age: Sex: Female Male Marital Status: Single
Demographic Information
Demographic Information Patient Name: Mailing Address: City: State: Zip Code: Home Phone: OK to Leave Message: Brief Extended Cell Phone: OK to Leave Message: Brief Extended Work Phone: OK to Leave Message:
MEMORIAL AND KATY SURGICAL SPECIALISTS. Patient Information
Patient Information Patient Name Last First Middle Address City State Zip Birthdate Age Sex M F Social Security# Race (Please circle) American Indian Asian Black Native Hawaiian Pacific Islander White
NEW PATIENT REGISTRATION PACKET
NEW PATIENT REGISTRATION PACKET Today s Date DOB: Social Security # Last Name: First Name: Previous/Nickname: Sex: Male Female Marital Status: Married Single Divorced Widowed Other Patients Race: American
Patient Information. Insurance Information Who is responsible for this account? Relationship to Patient. Insurance Co: Member ID:
Patient Information Today s Date: Birth Date: SS#: First Name: M. I.: Last Name: Address: City: State: Zip: Sex: M F Age: Email: Cell: ( ) Home: ( ) Emergency Contact: Relationship: Cell: ( ) Home: ( )
PATIENT INFORMATION. Caucasian or White Male Female. Unknown IN CASE OF EMERGENCY
Name (Last, First, Middle Initial): PATIENT INFORMATION Salutation: Mr. Social Security # Preferred Language: Race: Ethnicity: American Indian or Alaska Native Hispanic or Latino Asian Not Hispanic or
Please print and complete all the enclosed forms and bring them to your first appointment.
Dear Valued Patient, Thank you for requesting an appointment in our office. Please print and complete all the enclosed forms and bring them to your first appointment. When you arrive at our office for
FOOT AND ANKLE WELLNESS CENTER DR. LEONARD E. VEKKOS
FOOT AND ANKLE WELLNESS CENTER DR. LEONARD E. VEKKOS NAME: LAST FIRST MIDDLE ADDRESS: STREET APT# CITY STATE ZIP HOME # ( ) WORK# ( ) CELL# ( ) E-MAIL: PREFERENCE: HOME: AGE: DATE OF BIRTH: SS NO.: MALE
Alaska Center for Dermatology, P. C Piper Street Suite T4-020 Anchorage, AK telephone fax
3841 Piper Street Suite T4-020 Anchorage, AK 99508 telephone 907.646.8500 fax 907.646.9760 Please print all information clearly. Patient Patient Registration Form Name of Birth / / first middle initial
Phoenix Neurology and Sleep Medicine Phone: (623) Fax: (623)
Patient Information Date: Name: SSN (Last) (First) (MI) Address City State Zip Code Home # Cell # Work Sex Male Age DOB Married Single Divorced Female Widowed Other Email Address Employed? No Yes Employer
PATIENT REGISTRATION FORM
Today s Date: PATIENT REGISTRATION FORM PATIENT INFORMATION Last Name: First: Mi. Init: DOB: Age: SSN: Gen: M F Marital Status: S M D W Race: African American American Indian Asian Caucasian Hispanic Pacific
PS CHIROPRACTIC PATIENT CASE HISTORY
PS CHIROPRACTIC PATIENT CASE HISTORY Personal Information Last Name First Name Middle Initial Address: City: State: Zip: Home Phone: - - Work Phone: - - Cell Phone: - - Date of Birth: age Social Security
Patient Name: Male Female Married Divorced Widowed Single. SSN: Date of birth: Address: Phone: (home) (cell) (other) Emergency contact name:
Patient Information: Patient : Male Female Married Divorced Widowed Single SSN: of birth: Address: Phone: (home) (cell) (other) Emergency contact name: Relationship to patient: Emergency contact phone:
Allergies None Penicillin Sulfa Drugs Codeine Aspirin Tape Latex Iodine-Shellfish. Other allergies: Medications
Today s Date: Height Weight Shoe size (CIRCLE) Allergies None Penicillin Sulfa Drugs Codeine Aspirin Tape Latex Iodine-Shellfish Other allergies: Medications SOCIAL HISTORY (CIRCLE) Do you smoke? No Yes
PATIENT REGISTRATION INFORMATION Initial
PATIENT REGISTRATION INFORMATION Date Initial PATIENT S PERSONAL INFORMATION Please complete both sides of this form. Marital Status: Single Married Divorced Widowed Male Female Name: ( ) last name first
SHEDDON PHYSIOTHERAPY AND SPORTS CLINIC
Patient Name: Date of Birth: / / Last First Day Month Year Address: City: Home Tel: Other Tel: Postal Code: *E-mail: Family Physician: Do you have a Doctors referral? How did you hear about us? If so,
Center of Excellence in Spinal Care. Patient Information. If Patient is a minor Guarantor Name: If Patient is a minor Guarantor Social Security #:
Center of Excellence in Spinal Care Patient Information Patient Name: Patient Date of Birth: Today s Date: Current Age: Sex (Circle One) Male Female Patient Social Security Number: If Patient is a minor
PATIENT REGISTRATION FORM Patient Information. Last Name: First Name: MI: Date of Birth: Gender: M F Social Security #: Address: Street
Today s Date: Patient ID # [for office use only] Referring Physician PATIENT REGISTRATION FORM Patient Information Last Name: First Name: MI: Date of Birth: Gender: M F Social Security #: For Minors please
Your appointment at Dry Eye Institutes of America is scheduled on, at am/pm at our Grapevine location.
Dear New Patient, Thank you for choosing Dry Eye Institutes of America. We strongly believe in a TEAM approach to patient care and our team is committed to providing a smooth patient experience. Our holistic
Welcome to Compass Medical!
ELECTRONIC FORM DISCLAIMER: Compass Medical is deeply committed to protecting our patient's rights to privacy and safeguarding patient information. Please know we are working hard to bring our patients
PEDIATRIC PATIENT REGISTRATION GALEN MEDICAL GROUP, PC
PEDIATRIC PATIENT REGISTRATION GALEN MEDICAL GROUP, PC Your Child: Name Your Child s Full Name: Child Goes By: Gender: Male Female DOB: Age: SS#: Child s Home Address: City: State: Zip: Phone: Primary
Referring Physician: Primary Care Physician: Other Physician(s)/Specialty: EMERGENCY CONTACT INFORMATION INSURANCE INFORMATION
PATIENT INFORMATION Name: Date of Birth: Sex: Male Status: Single Married Divorced Widowed Other 502 Elm Street NE Language: Female Race: American Indian or Alaska Native Native Hawaiian or Or Pacific
PATIENT DEMOGRAPHICS. Primary Insurance: Policy #: Group #: Secondary Insurance: Policy #: Group #:
TEXAS DIABETES & ENDOCRINOLOGY, P.A. 6500 North Mopac*Bldg. 3, Ste. 200*Austin, TX 78731 5000 Davis Ln*Ste 200*Austin, TX 78749 170 Deep Wood Dr*Ste. 104*Round Rock, Tx 78681 Phone: (512) 458 8400*Fax:
Welcome to Our Practice
Welcome to Our Practice Greater Baltimore Medical Center (GBMC) welcomes you to our practice. We are dedicated to providing you with the kind of care that we would want for our own loved ones. This Information
PODIATRIC REGISTRATION AND HISTORY Dr. Peter F. Gregory, D.P.M.
Dr. Peter F. Gregory, D.P.M. Patient s Name: Date: / / Address: City State Zip Date of Birth: / / Sex: Male Female Home Phone: Cell Phone: Business Phone: Email: (Please check preferred method of contact
Automobile (No Fault) Insurance Assignment of Benefits
Automobile (No Fault) Insurance Assignment of Benefits To my auto insurance carrier: Name of Insurance: Claim/ Policy No: Date of Accident: Adjuster: I,, request that payment of authorized medical benefits
ELYSE S. RAFAL, F.A.A.D.
ELYSE S. RAFAL, F.A.A.D. Welcome to our practice. Thank you for placing your trust in us. We look forward to serving you with quality and compassionate care. Patient Information Today s : First Name: M.I.
PATIENT INFORMATION FORM
PATIENT INFORMATION FORM PATIENT INFORMATION Patient Name Last First Date of Birth Age Street Address Male Female City State Zip Code Social Security Number Home Phone Work Phone Cell Phone E-Mail Employer
Dr. Jeff Eidsvig, DC,ART,TPI-CGFI 3060 Communications Parkway, Suite #104 Plano, Texas 75093
Dr. Jeff Eidsvig, DC,ART,TPI-CGFI 3060 Communications Parkway, Suite #104 Plano, Texas 75093 New Patient Information/ Change of Information Date: New PT: Info Change: Patient Name: Age: Date of Birth:
Patient Health Information Consent Form
Patient Health Information Consent Form We want you to know your Patient Health Information (PHI) is going to be used in this office as well as your rights concerning those records. Before we will begin
Registration Information
Nevada Spine Center, LLC Registration Information Date Chart# D.O.B 10195 W. Twain Avenue Suite B Las Vegas, NV 89147 Patient Name SSN: Employer Drivers License # Required by the State of Florida Agency
Dear Patient: Please complete this questionnaire. You answers will help us determine if chiropractic care can help you. Thank you.
Dear Patient: Please complete this questionnaire. You answers will help us determine if chiropractic care can help you. Thank you. Name: Social Security: Address: City: State: Zip: Birthdate: Age: E-mail
WEST COAST VASCULAR PATIENT INFORMATION LAST FIRST MI BIRTHDATE SS# PHONE ADDRESS CITY ST ZIP EMPLOYER ADDRESS OCCUPATION WORK PHONE EXT
C. Shawn Skillern, M.D. Li Sheng Kong, M.D. Sydney S. Guo, M.D. Edward N. Li, M.D. Kevin M. Casey, M.D. Sara J. Runge, M.D. WEST COAST VASCULAR 100 North Brent Street, Suite 201 I Ventura, CA 93003 2100
Patient Registration WELCOME TO OUR OFFICE
Patient Registration WELCOME TO OUR OFFICE Date of Birth: Home Address: Apt / Unit: City: State: Zip: SSN: Telephone: Home: Cell: Work: Email: Marital Status: Name of Spouse / Partner: Preferred method
CLEAR CHOICE CHIROPRACTIC CHILDREN S HEALTH HISTORY FORM
CLEAR CHOICE CHIROPRACTIC CHILDREN S HEALTH HISTORY FORM Today s Date ABOUT THE CHILD Name Age Date of Birth Gender M F Height Weight Home Address City State Zip Names and Ages of Siblings Parent A Name
4) Address: City, State, Zip Code 5) Gender: Male Female 6) Date of Birth (DOB): / /
A) PATIENT INTAKE/TREATMENT FORM 1) Patient Name: 2) Social Security #: 3) Home Phone number: ( ), Cell: ( ), Work: ( ) 4) Address: City, State, Zip Code 5) Gender: Male Female 6) Date of Birth (DOB):
CHIROPRACTIC HEALTH QUESTIONNAIRE
CHIROPRACTIC HEALTH QUESTIONNAIRE Name: SS#: Today s Date: / / Address: City: State: Zip: What you prefer to be called: Age: Birthdate: / / Handedness: Height: Weight: Number of Children: Male Female Marital
Name: Social Security: Address: City: State: Zip: Birthdate: Age: address: Cell Telephone: ( ) Fax: ( )
Dear Patient: Please complete this questionnaire. You answers will help us determine if chiropractic care can help you. If we do not sincerely believe your condition will respond satisfactorily, we will
PAGE INTENTIALLY LEFT BLANK
PAGE INTENTIALLY LEFT BLANK OFFICE DIRECTIONS Jordan Young Institute is located on Cleveland Street off Newtown Road. Cleveland Street from the Pembroke area ends at Clearfield. There is no direct roadway
AVIDAPT avidapt.com
AVIDAPT 1391 Dublin Rd, Columbus, OH 43215 614-487-9715 avidapt.com Welcome to Avida PT. The purpose of this letter is to provide you with some helpful information to prepare you for your visits to our
Welcome to our Pediatric Orthopedic Office
cbsortho.com Welcome to our Pediatric Orthopedic Office Listed below are helpful hints to better understand our orthopedic office and how to complete the patient packets for faster insurance response.
MALINA CHIROPRACTIC 3826 N. Druid Hills Rd Decatur Georgia Office Fax
MALINA CHIROPRACTIC 3826 N. Druid Hills Rd Decatur Georgia 30033 Office 404-352-3609 Fax 404-325-8859 Car Accident Questionnaire Name: Age: Date of birth: LAST FIRST MIDDLE Social Security #: Male Female
Patient Information. Referred by: Primary Care Physician: Last Name: First Name: Mr. Mrs. Miss Other Middle Name: Preferred Name:
Patient Information Referred by: Primary Care Physician: Last Name: First Name: Mr. Mrs. Miss Other Middle Name: Preferred Name: Date of Birth: / / Age: SSN: - - Address: City: County: State: Zip: Email
Maragh Dermatology. ( ) New Patient ( ) Name Change ( ) Address Change. Today s Date. Patient Name: Last First MI Male ( ) Female ( )
Maragh Dermatology ( ) New Patient ( ) Name Change ( ) Address Change Today s Date Patient Name: Last First MI Male ( ) Female ( ) DOB / / Marital Status ( ) Married ( ) Single ( ) Other Spouse Address
Advanced PT, LLC 200 W Douglas Ave, Ste 1040 Wichita, KS (866)
200 W Douglas Ave, Ste 1040 Wichita, KS 67202 (866) 412-5554 Welcome to Advanced PT, LLC. We are honored that you have chosen us as your therapy provider. Our goal is to provide the highest quality of
NORTH TEXAS ARRHYTHMIA ASSOCIATES, PA
Demographic Information Name of Birth Sex Male / Female Social Security Number Email Marital Status Single / Married / Widowed / Divorced / Other Mailing Address City/State Zip Code Primary Phone Secondary
Registration Form. Gender: Male Last Name First Name Middle Initial Female. - - / / Social Security Number Date of Birth Age Occupation / Employer
Registration Form General Information Have you been treated by us before? Yes No Gender: Male Last Name First Name Middle Initial Female Social Security Number of Birth Age Occupation / Employer Street
PATIENT INFORMATION FORM RICHARD L. MALINICK, M.D. ORTHOPAEDIC SURGERY 1125 Via Verde, San Dimas, CA
Email Address Last Name First Name Previous Name Address City State Zip Country Social Security - - Home Phone - - Cell Phone - - Work Phone - - Ext Drivers License State Responsible Party SELF (use info
Endocrinology of the Rockies, PC. PATIENT REGISTRATION FORM E. 9th Ave. Ste. 245, Denver, CO 80220
1 PATIENT REGISTRATION FORM 2018 4545 E. 9th Ave. Ste. 245, Denver, CO 80220 Patient Name (Last, First, M.I.): Prefer to be called: Address: City: State: Zip: Home phone: ( ) Work phone: ( ) Day phone:
Dr. Jeff Eidsvig, D.C., TPI-CGFI 3060 Communications Parkway, Suite #104 Plano, Texas Patient Insurance Information
Improving Lives & Performance Dr. Jeff Eidsvig, D.C., TPI-CGFI 3060 Communications Parkway, Suite #104 Plano, Texas 75093 972-312-9310 New Patient Information / Change of Information : New Patient Change
New Patient Registration Form
New Patient Registration Form Patient Information Name: (First) (Middle) (Last) SSN: of Birth / / Sex: Male Female Street Address (or PO Box): City: State: Zip: Marital Status: Single Married Divorced
Patient Name: Date of Birth: Today s Date: First Middle Initial Last PACIFIC UROLOGY
PACIFIC UROLOGY 100 N. WIGET LANE, SUITE 290, WALNUT CREEK, CA 94598 - (925) 937-7740, FAX (925) 933-9868 2222 EAST STREET, SUITE 250, CONCORD, CA 94520 - (925) 609-7220, FAX (925) 689-3298 5201 NORRIS
PATIENT PROFILE. Marital Status: Please Check One [ ] Single [ ] Married [ ] Divorced [ ] Widowed. Address: City: Zip: Address: City: Zip:
![PATIENT PROFILE. Marital Status: Please Check One [ ] Single [ ] Married [ ] Divorced [ ] Widowed. Address: City: Zip: Address: City: Zip:](/thumbs/82/85694847.jpg "PATIENT PROFILE. Marital Status: Please Check One [ ] Single [ ] Married [ ] Divorced [ ] Widowed. Address: City: Zip: Address: City: Zip:")
PATIENT PROFILE PATIENT INFORMATION: Name: Date of Birth: Marital Status: Please Check One [ ] Single [ ] Married [ ] Divorced [ ] Widowed Address: City: Zip: Home#: Message#: Name of Primary Physician,
New Patient Information
New Patient Information LAST FIRST NAME NAME M.I. DATE OF SOC. MARITAL BIRTH SEC. SEX STATUS PRIMARY ADDRESS PHONE CELL CITY STATE ZIP PHONE WORK EMPLOYER PHONE REFERRING/ LAST YOUR PRIMARY PHYSICIAN SEEN
NO-FAULT PATIENT INFORMATION *** PLEASE COMPLETE ALL INFORMATION REQUESTED FOR OUR RECORDS *** Date:
NO-FAULT PATIENT INFORMATION *** PLEASE COMPLETE ALL INFORMATION REQUESTED FOR OUR RECORDS *** Date: Last Name: MI: First Name: DOB : SEX : SS # : Address: City: State Zip Code: Phone (Home): Phone (Cell):
NORTH TEXAS DIABETES & ENDOCRINOLOGY OF PLANO
Demographic Information Name Sex Male / Female Social Security Number Email Marital Status Single / Married / Widowed / Divorced / Other Mailing Address City/State Zip Code Primary Phone Secondary Phone